1.Decreased red cell production a.Stem cell damage - neutrophils, platelets often affected also b.Defective red cell maturation 2.Increased red cell destruction (hemolysis) a.Intrinsic defect in red cell leading to shortened lifespan b.External factors in blood or blood vessels destroy red cells 3.Blood loss ANEMIA Classified by cause

 Increased rate of red cell destruction  Increased rate of production - increased reticulocytes  Red cell destruction causes increased bilirubin production and jaundice  Most red cell destruction occurs in spleen splenectomy may cause improvement HEMOLYTIC ANEMIA

Hemolytic anemia: low hematocrit, plasma too yellow due to high bilirubin

INHERITED HEMOLYTIC ANEMIA Sickle cell anemia  Mutation changes structure of hemoglobin  Mutant hemoglobin (deoxy form) polymerizes in cells and damages cell membranes membrane damage causes hemolysis hemoglobin crystals change cell shape to "sickle" sickled cells are rigid and block small blood vessels, causing tissue damage  Genetics: mainly affects those of African and Middle Eastern descent; recessive inheritance (carriers partially protected from malaria) O2O2 “Sickled” cell

SICKLE CELL ANEMIA Sickle cellNormal

Sickle CellNormal red cell Sickle cells inflexible, can’t do this

Sickle cell anemia - pathophysiology

Retinal vessel occlusion in sickle disease

 Production of "autoantibodies" against one's own red cells  Antibodies coat cells and lead to destruction in spleen and liver  Positive Coombs test (detects antibodies on red cells) in most cases  Treatment: corticosteroids, splenectomy, i.v. gamma globulin IMMUNE HEMOLYTIC ANEMIA

TRANSFUSION REACTION  Giving a person blood of the wrong type may cause destruction of the transfused cells (hemolysis) by antibodies in the recipient's blood  The most serious reactions occur with blood mismatched for antigens in the ABO system: giving O patient A, B, or AB blood giving A patient B or AB blood giving B patient A or AB blood  In such instances there may be very rapid hemolysis accompanied by shock, kidney failure, bleeding, and death

 Caused by maternal antibodies against antigens on fetal red cells (usually Rh antigens); mother usually exposed (sensitized) to Rh antigen during prior pregnancy  These antibodies cross the placenta and cause destruction of fetal red cells  Infant liver unable to properly metabolize hemoglobin breakdown products (bilirubin)  Stillbirth or anemia, jaundice, and brain damage may result  Prevention: prevent sensitization by giving antibody against Rh factor (Rhogam) to Rh-negative woman soon after delivery of Rh-positive child HEMOLYTIC DISEASE OF THE NEWBORN

 Definition: increased total red cell volume high hematocrit thick blood can cause thrombosis, other circulatory disorders  Polycythemia vera: increased, unregulated red cell production Most cases due to an acquired mutation in marrow cells that makes red cell precursors much more sensitive to erythropoietin  Secondary polycythemia: increased erythropoietin production due to decreased oxygen delivery to kidney Often due to low levels of oxygen in the blood POLYCYTHEMIA

 Neutropenia (decreased neutrophils) Decreased production (bone marrow failure, cancer chemotherapy) Increased consumption (some infections, enlarged spleen, autoimmune)  Increased risk of infection when neutrophil count low  Neutrophilia (increased neutrophils) Increased production due to physiologic stimuli (e.g., infection) Increased production due to bone marrow neoplasm NEUTROPHIL DISORDERS

neutrophils 0neutrophils 19,000neutrophils /31/9711/7/972/12/98

CANCERS OF THE BLOOD AND LYMPHATIC SYSTEMS

 Malignant proliferation of white cells and/or their precursors (blasts)  Myelogenous (neutrophil precursors) Acute myelogenous leukemia (AML) Chronic myelogenous leukemia (CML)  Lymphocytic Acute lymphocytic leukemia (ALL) Chronic lymphocytic leukemia (CLL)  Chronic leukemias: more mature cells, slow-growing  Acute leukemias: immature cells (blasts), fast- growing LEUKEMIA

 Bone marrow failure (marrow fills with leukemic cells) anemia neutropenia (infections) thrombocytopenia (bleeding)  Leukemic cells in blood may impair circulation  Leukemic cells in other organs spleen, lymph nodes skin brain  Toxic substances from leukemic cells uric acid (gout, kidney failure) proteolytic enzymes (tissue damage, bleeding) PATHOPHYSIOLOGY OF LEUKEMIA

Leukemia White cells

GUM INFILTRATION IN ACUTE LEUKEMIA

SKIN INFILTRATION IN ACUTE LEUKEMIA

CEREBRAL HEMORRHAGE IN ACUTE LEUKEMIA

PURPURA IN LEUKEMIA

DISSEMINATED FUNGAL INFECTION IN ACUTE LEUKEMIA

 Acute myelogenous leukemia (AML) adults > children fatal if untreated remission, occasional cure possible with intensive chemotherapy sometimes curable with bone marrow transplant  Acute lymphocytic leukemia (ALL) children and adults (most common childhood leukemia) fatal if untreated curable with chemotherapy or bone marrow transplantation Cure rates in children > 75% ACUTE LEUKEMIAS

DIFFERENTIATION OF NEUTROPHILS AND RED CELLS Cells cannot divideCells capable of division

NormalAML Bone marrow in acute leukemia

Immature cells (blasts) in acute myelogenous leukemia Mature lymphocytes in chronic lymphocytic leukemia

 Chronic myelogenous leukemia (CML) rare in children treatable but often fatal within 5-10 years  Newer treatments will probably improve the prognosis may be curable with bone marrow transplantation  Chronic lymphocytic leukemia (CLL) almost all patients middle-aged and older treatable but incurable not all patients need treatment, many live > 10 years CHRONIC LEUKEMIAS

Enlarged lymph nodes (lymphadenopathy) in chronic lymphocytic leukemia

 Cancer of lymphocytes or their precursors  Forms tumors in lymph nodes, spleen, bone marrow, other organs Sometimes in blood - overlap with lymphoid leukemia  Many different kinds - spectrum of severity Hodgkin's vs non-Hodgkin's B-cell vs T-cell Mature vs immature lymphoid cells Fast vs slow-growing  Usually treatable, sometimes curable (chemotherapy, radiation, marrow transplantation) LYMPHOMAS

 LOW GRADE Cells appear mature Good news: slow-growing - patients may live many years with disease Bad news: treatable but generally incurable Usually affect older people  HIGH GRADE Cells less mature The most aggressive forms resemble acute lymphoblastic leukemia Good news: often curable with chemotherapy Bad news: faster-growing, fatal in months if not treated or treatment doesn't work Some varieties occur in children Example: Burkitt lymphoma (resembles acute leukemia)  Rule of thumb: the less mature the cancer cell, the faster growing the lymphoma, and the more likely the disease is to affect younger people and to be curable NON-HODGKIN'S LYMPHOMAS Many types, complex classification scheme

 Probably a cancer of lymphocytes (lymphoma)  Almost always begins in lymph nodes  Spreads gradually to other lymph nodes & organs  stage = extent of spread  Relatively common in young adults  Curable in many cases with radiation or chemotherapy HODGKIN'S DISEASE “Reed-Sternberg” cell characteristic of Hodgkin’s disease

Stage I: single lymph node or contiguous group of nodes Stage II: more than one node group, same side of diaphragm Stage III: confined to nodes (and/or spleen) but present on both sides of diaphragm Stage IV: spread outside nodes (liver, bone marrow, lung, etc) Presence of symptoms (fever, weight loss, night sweats) designated by "B" after stage (no symptoms = "A") Lower stage disease often treated with radiotherapy; higher stage disease with chemotherapy HODGKIN’S DISEASE Staging

HODGKIN’S DISEASE Response to treatment Before treatmentAfter 6 months (Treatment completed) After 7 years

 Cancer of plasma cells (antibody-producing cells)  Most patients have monoclonal immunoglobulin (antibody-like protein) in blood or urine This protein may damage kidneys, other organs  Bone destruction, bone marrow failure common MULTIPLE MYELOMA

Plasma cell Red cells stuck together by abnormal protein (rouleaux)

BONE LESIONS IN MYELOMA